The Effect of Graft Harvest and Skin Incision Angle on Sensory Disturbance in ACL Reconstruction With Semitendinosus-Gracilis Tendon Graft: A Randomized Controlled Trial and Cadaveric Study.

BACKGROUND: Injury to the inferior branch of the saphenous nerve (IBSN) and the subsequent loss of skin sensation after anterior cruciate ligament (ACL) reconstruction are common. The literature suggests that the incision angle may affect the incidence and area of loss of skin sensation. PURPOSE: To determine whether there is a difference in the incidence and area of altered sensory loss on the tibia between vertical (VI) and oblique (OI) incisions for semitendinosus-gracilis tendon graft harvest during ACL reconstruction. The cadaveric component was designed to determine whether there is a "safe zone" for incision by identifying the location and number of branches of the IBSN. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Patients (n = 37) were randomized to receive either VI or OI. Incidence and area of altered skin sensation were documented during at least 1 postoperative visit. In addition, 18 cadaveric knees were dissected. RESULTS: The presence or absence of hypoesthesia did not differ between groups postoperatively. Although no statistical differences between groups were seen in the total area of perceived altered skin sensation at 3 (P = .57), 6 (P = .08), 12 (P = .65), and 24 months (P = .27), data demonstrated a trend toward VI participants having a larger area of hypoesthesia at every time point. Among the 18 cadaveric specimens, 4 variations in the distribution of IBSN were noted: 18 (100%) had 1 branch, 14 (78%) had 2 branches, 6 (33%) had 3 branches, and 1 (6%) had 4 branches. No safe zone for incision could be identified. CONCLUSION: No difference was found between a vertical and an oblique incision with respect to incidence or area of sensory loss. Furthermore, it was not possible to identify a safe zone that would prevent transection of all nerves branches of the IBSN based on the cadaveric component of this study.

Using pre-operative MRI to predict intraoperative hamstring graft size for anterior cruciate ligament reconstruction.

PURPOSE: Large variation in tendon size between individuals makes hamstring graft diameter for anterior cruciate ligament (ACL) reconstruction unpredictable. Inadequate graft diameter may necessitate an alternative source of tissue requiring pre-operative planning. The purpose of this study was to determine whether magnetic resonance image (MRI) measurements and clinical anthropometric data are predictive of hamstring tendon graft diameter. METHODS: Data from 109 patients having ACL reconstruction with semitendinosus-gracilis (STGT) autograft were retrospectively evaluated. Cross-sectional area (CSA) of the gracilis tendon (GT) and semitendinosus tendon (ST) were determined from pre-operative MRI scans. Variables included pre-operative height, weight, body mass index (BMI), age and gender; and intra-operative graft diameter. RESULTS: Correlations between anthropometric variables, hamstring tendons CSA and intra-operative graft diameter were calculated. Multiple stepwise regression was performed to assess the predictive value of these variables to graft diameter. Sensitivity and specificity were calculated to evaluate the utility of MRI CSA measurements in accurately identifying inadequate graft diameter (<8 mm). All anthropometric variables were positively correlated with intraoperative graft diameter (p < 0.01). Semitendinosus-gracilis tendon CSA (p < 0.001) and STGT CSA and weight (p < 0.001) were significantly predictive models of graft diameter. Sensitivity and specificity were 79 and 74 %, respectively. CONCLUSION: The strongest indicators of a four-stranded STGT graft for primary ACL reconstruction were STGT CSA on MRI plus weight. Measurement of graft diameter can be performed pre-operatively via MRI to identify tendons that may be of inadequate size for ACL reconstruction. This can assist with surgical planning to determine the most appropriate graft choice. LEVEL OF EVIDENCE: III.

Effects of Rituximab and Infliximab Treatment on Carboxypeptidase B and Its Substrates in RA Synovium.

OBJECTIVE: We evaluated the synovial effects of 2 potent biologic rheumatoid arthritis (RA) therapies, focusing on their effect on the expression level of carboxypeptidase B (CPB) and its substrates. METHODS: Patients with RA receiving infliximab (IFX; n = 9) or rituximab (RTX; n = 5) had an arthroscopic synovial biopsy at baseline and 16 weeks posttherapy. Expression of CPB, C5a, osteopontin (OPN), CD3, CD20, CD55, and CD68 was assessed by immunohistochemistry and image analysis, and compared with OA synovium. RA disease activity score was assessed at multiple timepoints. Serial serum samples were analyzed for soluble CPB and C5a levels. RESULTS: The baseline clinical characteristics of patients receiving IFX and RTX were similar. At the time of the second biopsy, 50% of patients had achieved a European League Against Rheumatism good or moderate response. At baseline, expression of CPB, C5a, and OPN was markedly higher in RA compared with OA synovium and correlated with mononuclear cell infiltration. There was an overall reduction in synovial expression of CPB, C5a, and OPN paralleling a reduction in mononuclear cell infiltration, but these changes were not associated with clinical response. After an early reduction in serum C5a levels, these returned to baseline levels at later timepoints. CONCLUSION: In response to IFX and RTX treatment, RA synovial expression of CPB, C5a, and OPN decrease independently of the clinical response, reflecting the complex proinflammatory and antiinflammatory effects of this pathway.

Reliability of tunnel angle in ACL reconstruction: two-dimensional versus three-dimensional guide technique.

PURPOSE: To compare the reliability of tibial tunnel position and angle produced with a standard ACL guide (two-dimensional guide) or Howell 65° Guide (three-dimensional guide) in the coronal and sagittal planes. In the sagittal plane, the dependent variables were the angle of the tibial tunnel relative to the tibial plateau and the position of the tibial tunnel with respect to the most posterior aspect of the tibia. In the coronal plane, the dependent variables were the angle of the tunnel with respect to the medial joint line of the tibia and the medial and lateral placement of the tibial tunnel relative to the most medial aspect of the tibia. METHODS: The position and angle of the tibial tunnel in the coronal and sagittal planes were determined from anteroposterior and lateral radiographs, respectively, taken 2-6 months postoperatively. The two-dimensional and three-dimensional guide groups included 28 and 24 sets of radiographs, respectively. Tibial tunnel position was identified, and tunnel angle measurements were completed. Multiple investigators measured the position and angle of the tunnel 3 times, at least 7 days apart. RESULTS: The angle of the tibial tunnel in the coronal plane using a two-dimensional guide (61.3 ± 4.8°) was more horizontal (P < 0.05) than tunnels drilled with a three-dimensional guide (64.7 ± 6.2°). The position of the tibial tunnel in the sagittal plane was more anterior (P < 0.05) in the two-dimensional (41.6 ± 2.5%) guide group compared to the three-dimensional guide group (43.3 ± 2.9%). CONCLUSION: The Howell Tibial Guide allows for reliable placement of the tibial tunnel in the coronal plane at an angle of 65°. Tibial tunnels were within the anatomical footprint of the ACL with either technique. Future studies should investigate the effects of tibial tunnel angle on knee function and patient quality of life. LEVEL OF EVIDENCE: Case-control retrospective comparative study, Level III.

Augmentation of femoral fixation in hamstring anterior cruciate ligament reconstruction with a bioabsorbable bead: a prospective single-blind randomized clinical trial.

BACKGROUND: The EndoPearl is an adjunct to bioabsorbable interference screw fixation in the femoral tunnel in anterior cruciate ligament (ACL) reconstruction. The purpose of the study was to assess the clinical effectiveness of the EndoPearl using the KT-1000 Knee Arthrometer and the Mohtadi ACL Quality of Life (ACL-QOL) Questionnaire. HYPOTHESIS: The application of the EndoPearl in hamstring ACL reconstruction has no significant benefit when compared to conventional treatment in KT-1000 and ACL-QOL Questionnaire outcomes. STUDY DESIGN: Prospective single-blind randomized clinical trial. METHODS: ACL reconstruction with autogenous semitendinosus and gracilis tendons was performed on 35 patients. Preoperatively, 3 months, 6 months, and 18 months postoperatively, patients' knees were evaluated using the KT-1000 Knee Arthrometer and the ACL-QOL Questionnaire. RESULTS: Statistically significant differences were achieved in terms of KT-1000 side-to-side differences between the study group and the control group at 6 months and 18 months postoperatively; the mean side-to-side differences are significantly less in the study group when compared to the control group. Statistically significant differences were not detected when comparing the ACL-QOL Questionnaire between the two groups at all time intervals. CONCLUSION: The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased laxity up to 18 months postoperatively in terms of KT-1000 side-to-side differences.